Annie’s Story and the Hidden System Behind the Critical Error

Why This Episode Matters

Too many healthcare organizations still respond to safety events as if the main question is who made the mistake. This conversation offers a better lens: what in the system made the event possible, and how can leaders learn early enough to prevent the next one?

Using Annie’s story, Dr. Terry Fairbanks explains why strong event review matters, why timely response matters, and why healthcare falls short when it treats quality improvement and safety management as though they require the same skills. This episode gets beneath the language of safety and into the logic of safer systems.

Key Ideas Explored

• Annie’s story as a case study in how system failures get mistaken for individual failure 
• Why event reviews should begin immediately, even before every fact is known 
• The difference between product design, implementation, and real-world use 
• Why safety requires distinct competencies from traditional quality improvement 
• A practical model of primary, secondary, and tertiary prevention in safety 
• How hospitals could use existing data streams to identify hazards before harm occurs 

Takeaways for Quality Leaders

• Do not rush to discipline before a full systems-based review is complete 
• Treat early family communication and caregiver support as core parts of the safety response 
• Ask what design or implementation factors shaped the event 
• Make sure safety expertise is in the room during technology and device implementation 
• Stop assuming quality improvement training alone is enough for patient safety leadership 
• Invest in ways to detect weak signals and emerging hazards before they become events 
• Judge mitigation strategies by two standards: effectiveness and sustainability

Connect with Dr. Terry Fairbanks

LinkedIn

Twitter / X

Resources & Frameworks Referenced

• Annie’s Story 
• The MedStar Health National Center for Human Factors in Healthcare
• Systems-based event review
• AHRQ's CANDOR Framework 
• IHI's RCA2 Framework 
• Trigger tools 

Leading Quality is a podcast for healthcare leaders committed to improving systems, culture, and outcomes.

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Credits:

Host, Writer, and Executive Producer
Jason Meadows, MD

Produced by
Thrive Healthcare Improvement

Edited by
Milan Milosavljevic

Transcript

Glucose Crisis And Early Blame

SPEAKER_01 0:00

A patient who ended up in retrospect having low blood sugar was misinterpreted as having high blood sugar. Patient got more insulin and went downhill, had to be intubated. A nurse leader, along with their HR partner, suspended the nurse involved. Within two weeks, we had another very similar event on another unit. And at that point, the chief nursing officer of the hospital called me. And indeed, we did the review and we found many, many system components, including a major design flaw in the glucometer that really led to misinforming the staff about the glucose level.

Guest Background In Safety Science

SPEAKER_00 0:38

Welcome to Leading Quality, the podcast spotlighting the people moving healthcare forward from the front lines to the C-suite. I'm your host, Jason Meadows. Today I'm joined by Terry Fairbanks. Terry is the Chief Quality and Safety Officer at Medstar Health, where he leads system-wide efforts to improve patient safety, clinical quality, and reliability across a large academic health system. He is also the founder and founding director emeritus of the National Center for Human Factors in Healthcare, one of the most influential efforts in the U.S. to bring human factors engineering directly to the design of healthcare systems. His work sits at the intersection of medicine, engineering, and safety science, shaping how organizations think about clinical workflows, system design, and risk. Earlier in his career, Terry was a paramedic and is also trained as a human factors engineer, which gives him a unique perspective on healthcare that's both deeply practical and systems oriented. His work has been recognized nationally, including with the John M. Eisenberg Patient Safety and Quality Award, one of the highest honors in patient safety. He's also been part of national conversations, including conversations at the White House, on how we learn from harm and improve safety at scale. What I was particularly interested to explore in this conversation is how Terry's thinking has evolved over time, especially through work like Annie's story, which we'll get into, and how that's led him to challenge some of the core assumptions we make about safety learning and improvement in healthcare. Terry, welcome to the show. Thank you. It's great to be here. I wanted to jump right in. If you could give me a bit of a zoomed-out view of what brings you into this space. What's your your background that has led you kind of to this point?

SPEAKER_01 2:34

Well, I have it's a it's a great starting question because I have an unusual start. It's hard for me to have mentorship discussions because I kind of I didn't plan this out, but I I started as a um math and physics major. I was a math and physics major in undergrad, and then I went on to get a master's in industrial systems engineering with the whole focus on human factors and safety engineering, really. And my funding in that degree was in safety science. And the in that decade, it was really, you know, in my 20s, I was immersed in safety in other industries. I had very little to do with healthcare except for the fact that kind of on the side, and part of the way I paid my way through grad school, I was a paramedic and I did it volunteer and paid, and then kind of tied my background in because as I was getting near 30, I started working in an ER to become a better paramedic, basically part-time. And I loved the ER so much that I decided to do a career change and see if I could get into medical school. And I really at that point thought I was walking away from safety science and that background, and it was going to be a new career. And then I got in healthcare and really realized there was this deep disconnect that the stuff I had just spent the last decade doing in other industries wasn't really fully recognized in healthcare. And I was interested in transportation. My my first decade was a lot of transportation safety. I had gotten my private pilot's license. I had a real special interest in aviation safety. I had learned a lot about nuclear power safety. Um, but I had not done a lot in healthcare safety until I got into it and became an I, you know, I went to medical school to become an ER doctor. I started working in the ER and I really started to realize uh where the gap was.

SPEAKER_00 4:25

Yeah, and we we never know where those paths will lead. Certainly the, you know, in retrospect, the edited version looks like you had a whole plan the whole way, but it sounds like it was an interesting journey as it unfolded.

Annie’s Story And System Reviews

SPEAKER_00 4:36

And so I'm curious, maybe if we can jump right into one of the things we wanted to talk about today, which was Annie's story. And this is a story that you've, I think, shared widely and and uh maybe also in your your uh invitation to talks at the White House as well. Can you tell me a little bit about what Annie's story was?

SPEAKER_01 4:57

Sure. Well, I think um I'll start by saying Annie's Story is a is a four and a half minute video that we created at Med Star Health about 15 years ago. And the purpose of creating it was meant to be an internal training program for our 2,500 frontline managers, people like unit manager, uh nursing unit leaders, vice chairs of departments, people that were the frontline managers so that they could understand the importance of doing a full event review before taking a disciplinary response after an adverse event or a clinical event. That was the purpose of it. And so to give to give a little bit of background, starting with that and what our purpose and why we created the video, it's important to give some background on Med Star Health, where it was created, and why why we got to this point. And MedStar Health is a 10-hospital system in the DC and Baltimore region. Um, we have about uh 33,000 employees and about $9 billion annual revenue. So it's a good size program. And about 15, 18 years ago, in 2010, Medstar Health really went on a campaign to put patient safety as a very high priority. And in that, we had lots of kind of safety science-based, safety-oriented processes, including the we did these special event reviews. We call them systems-based event reviews. We think they're better than our than the traditional RCAs in healthcare. Uh, we think they get us to a better answer. And in this case, this was back in 2011, we had an event happen in in one of our big academic medical centers on a diabetes unit with a really good diabetes nurse, where a patient who ended up in retrospect having low blood sugar was misinterpreted as having blood high blood sugar. Um, the nursing staff communicated to the on-call hospitalists and they ordered insulin, and patient got more insulin and more insulin and went downhill, had to be intubated and put in the ICU. You know, within 24 hours of that event, the local uh nurse leader, along with their HR partner, suspended the nurse involved once they saw from the lab that the patient had had low blood sugar. And what happened after that is within two weeks, we had another very similar event on another unit which went down similarly but with a different nurse. And at that point, the chief nursing officer of the hospital called me. I was leading the Human Factor Center at the time, and I'll talk more about that in a little bit, but said, I think we need to do a deeper evaluation of this. I think it's more than the nurse. And indeed, we did the review and we found many, many system components, including a major design flaw in the glucometer that really led to misinforming the staff about the glucose level. So the discipline was reversed, everything was kind of smoothed over with that incident, but we realized that we had this world-class systems event review process that we not only did really well here at Med Star Health, but we were helping other systems learn how to do, but that it wasn't being consistently done, and that not every leader consistently understood the importance of activating this and activating our just culture policy and everything. So we created this video for that purpose. We never imagined that it would become a video that was used for that purpose by hundreds of health systems around the world. Um, and we're really proud of that. You know, it's funny, it's been so long ago now. I look younger in the video, but for a long time, I would go to national meetings and people would come up to me and say, Are you in that video? Uh and Annie has has become really herself, the nurse involved. Um, the nurse's name is Annie. And she's she's at first she didn't even want to do the video. It took a while to convince her, but she's now become somebody who's become a champion of this. Um, we've brought her to a couple national stages. She talks now more than a decade later about how the event has impacted her. So we're really proud of the video. It's had it's had a significant impact for um for many around the country.

SPEAKER_00 9:16

Yeah, and I've seen it. It's a great, a great video and a great example of how to do these these investigations well. So what were the the kinds of breakdowns, if you're able to share, that's that occurred in a case like that, that might individually feel small, but then can kind of all come together to to make a uh you know a really dramatic uh change in the patient's condition?

The Glucometer Design Trap

SPEAKER_01 9:40

It's a it's a great question. And the the event review, we're actually making a second video that goes into more detail about the event review because in this initial event review in the initial video when we produced it, our only goal was to show people the impact of not doing a full review. So we didn't go into the details. So there were several factors that we found, and it was it was interesting because to do the event review, one of the things we'll often do in our event reviews is simulation to really recreate the problem. And you know, in the morning checks of glucometers, you know how the the um usually the nursing staff or the PCT staff has to check on, I think on a daily basis, do the QC checks of the glucometer where they put the artificial fluid in and make sure it's within range. And what I didn't know, I learned during this event review, is that those you can buy those fluids to check glucometers for high and low, but not for for very high or very low, the critical high and critical low categories. There's no fluid available for those. So when we went to do the event review and we knew we needed to do a simulation to see what Annie was seeing, because she kept saying, I know it was saying that the blood sugar was high. I know it was. And everyone was like, Well, how could it be? We're looking at the labs, it was low. We actually waited for a patient to come into the ED with critically low blood sugar, and we used that a patient's blood. Uh, we went down and simulated it, and this was years ago, so we used our BlackBerry to videotape the actual glucometer. And what we learned was striking, the operating system of this glucometer was such that as soon as the result popped up, it popped up H I or L O, in this case, um L O. And then immediately, right on top of it, a message appeared that it turns out in retrospect, the company did not design the message. It's one of those things that during implementation, they come to their client and say, What do you want this message to say? And this message said critical value for blood sugar greater than 600 resend labs. And all that Annie kept seeing is greater than 600. That's what popped out at her. And of course, it covered up the it covered up the LO, which was the message saying critically low. And this really brought out an interesting point. It's similar to EHRs. I I've done a lot of studies in my past of EHR safety design. And when we looked at that, we concluded that from a human factors perspective, there were three problems with safety in EHR. One is the design of the product itself, the second is the implementation of the product, and the third happens in the actual use of the product, which which can be impacted by the first two, but we but that often can be from training and proper use of the individual. And this really applies in this medical device story because the vendor, I think, probably worried about liability, I'm not sure why, but they come to the hospital system and say, what do you want this message to say? And it's one of two pages of configurations that need to be done before implementation. And I'll just say a side note of what we've done since then is we've started asking vendors when we're implementing their devices, we say to them, you've implemented this device at thousands of hospitals. This is the first time we've ever done it. You're the expert in what these should what these configurations should be. So we want you to tell us what the optimal configurations are. And it's interesting because some vendors are very reluctant to do that. Sometimes it's just that they they want, they think that the client always, you know, everyone thinks they're different and they're special, and so they just want to allow that. But other times they seem reluctant, and I think it may be because of um liability concerns. So I'm getting tangential, but that was one major finding is that design piece. And when I talk about that, I talk about the fact that it wasn't just a poor design with the pop-up coming immediately to the to the um to cover up the main message, but it was also the implementation problem. And it turns out we had we have 10 hospitals. We had chosen five different messages uh as we implemented these glucometers system-wide. And it and when we looked at that further, you know, keep asking why. Why did we do that? It's because the vendor was asking the local lab manager at each hospital what the configuration would say, because the lab manager was the main client in implementing glucometers. And so that that kind of follows into when we try to implement safety science and integrate it into our overall safety program as a health system. We always say that we should have a safety opinion in the room, make sure we have the right safety expertise in the room when we're doing implementations. So that that's there were several other pieces to the event review. I'll just give one other that I think is really interesting. Is this was a um a diabetes unit. Diabetes units, the nurses there are deeply specialized and expert in managing diabetic patients. And this was a very Annie was a very experienced diabetes nurse. She was the one that was the go-to for doing orientation of new nurses. She was a well-regarded, great clinician, still is, but she had never seen a critically low blood sugar pop up in the glucometer because they're so good at managing. So we went back and we thought that was interesting. We went back and looked at the last 80,000 blood sugar checks in this hospital, and 0.1% of them were critical low, and almost all of those were in the ED with patients that came in with critical low. It's just not something we see. And so until this experience occurred, we really people didn't understand that this is how the pop-up messaging worked on the glucometer device itself.

SPEAKER_00 16:00

I wanted to pause for a moment to invite you into something I'm starting with this podcast. If something from this episode connected with your own experience, where you've seen it work or not work, I'd love to hear about it. There's a short link in the show notes where you can share what you're seeing in your own work. It takes about a minute. I read every response, and over time I'll be sharing what we're learning together in future episodes and in other ways, and giving shout-outs during future episodes to people in the community who share ideas that really move the conversation forward. If you're up for it, I really value your perspective. Thanks.

Responding Fast After SUOs

SPEAKER_00 16:41

I know you also talked about with these event reviews uh that they need to occur, I think, with with support of the people involved, but also to to begin immediately, even before all the information is known. What happens to the truth of an event uh in the hours and days after it occurs?

SPEAKER_01 16:57

I want to make sure I understand that question right. You're saying what happens to the truth?

SPEAKER_00 17:02

Yeah, I guess why why jump on it so immediately? What's what is the the added value in that? I I Oh I see. I'm curious to know your perspective.

unknown 17:12

Yeah.

SPEAKER_01 17:13

Yeah. Well, let me talk about first I'll just frame it in what we we teach our teams as the right, the correct response after an event. And and first I'll say that we ask them to trigger this response based on what we call a serious unanticipated outcome. We even have an acronym, SUO. Everyone in our health system knows what an SUO is. The reason that we frame it that way is if we say to people, we want you to react to an adverse event or a medical error or a serious safety event, the local team always takes a little bit of time to figure out is it one of those things? Because you have to, it's not always obvious if there's actually been an error or something that's triggered an adverse event or a violation of standard of care. It takes a little bit of time to get that information. And in the meantime, we realize that often the patient or their family or the clinical team members are uncomfortable with an unexpected event and we lose that crucial time to respond. So that's the first thing I'll say is that we say to our teams anytime there's an unexpected event, an SUO is defined as an unexpected clinical event, either by the patient, their family member, or clinician, then it should trigger a response that has four main components. You know, that even just to make that point further, that in even in covers things that maybe in a in a surgical situation, a surgeon might say is it is an expected side effect or something that can go wrong, an anticipated complication or a known complication. Um, so the clinicians may not actually find it to be an unexpected outcome, but the patient and their family may be. Maybe they didn't hear it in the consent or their. So we still say to trigger. And the reason for that is it gives us the four things are early reporting, early patient and family communication, which allows us to really quickly get in there, have an open and honest conversation with them, tell them that our policy is to be open and honest about things, and we'll let them know what we learn as we learn it and that we're concerned too. So that, and that's a crucial time for the patient and family, because it's scary for them to be now being taken care of by a team that they don't trust anymore because of the what they're questioning. So to have a liaison in there, somebody who's reassuring them that we're caring for them, creates this immediate trust, which is helpful in s in so many ways. The third thing is care for the caregiver. You know, we all know stories where the leaders thought everything was okay and the clinician felt so awful that there can be bad outcomes, there can be suicides. So we we know that's the worst case scenario, but there's lots in between that we want to take care of. So we make sure that the clinical teams are okay and we intervene where necessary. And then the fourth reason we want an early response, which gets to your question, is what we call early learning. And we find that to get in there right away to do interviews, to be able to capture the equipment before it goes back to biomedical engineering, or you know, if it's a if it's a stretcher that that there was a fall with, you want to capture that stretcher, you want to be able to make sure it's operating right and have it be part of the event review. Figuratively, I always like to say for those of us that have been around a while, we remember how the strips, when the alarms would go off, the strips would just kind of like keep rolling off the off the monitor onto the floor, and then they'd eventually make it to the wastebasket, and a few strips would be taped onto the chart. But it literally lets us get in there and get the strips out of the wastebasket, you know, so that we've captured everything. And that's the fourth, that fourth reason I think gets it your question about why it helps us get to the truth. Really, we can then combine the two other pieces of care for the caregiver and early comfort and communication with the family, allows us to be asking questions, learning about the event in real time when everybody's memories are fresh. At the same time, we're reassuring them uh that we have their back and that we're we're going to make sure that every everybody's okay from this. Those are um, I think the most important components for getting in there early. It doesn't mean necessarily that we do a rapid event review. Sometimes the full event review can take a couple weeks because maybe we had multiple specialties involved with the care. It has to go out to two or three peer reviews to be able to understand standard of care. Um, but getting it started early is what we find is really helpful.

unknown 21:59

Yeah.

SPEAKER_00 22:00

Uh uh, you know, I've also understood that you have you talked about the need for better real-time monitoring in our systems and so hour-by-hour kind of awareness of the safety situation in uh in our hospitals.

Real-Time Safety Signals And Triggers

SPEAKER_00 22:14

And so I'm wondering what that actually looks like if if we did that. I you know, I think a lot of people in our audience might be accustomed to knowing about events that happened a day ago, a week ago, depending on their rank, depending on how their hospital works, but certainly a uh a noticeable delay between the event occurring and somebody who might have the ability to intervene uh to know about it. What would it look like to to have hour-by-hour awareness of safety?

SPEAKER_01 22:46

I mean, most people are familiar with the emergence, the uh the emergence of trigger tools, and I think we're gonna we're gonna see a real explosion of that in the next few years in a good way with um the ability to use AI and more data coming together. A AI is probably not the limitation right now, as much as having everything, all the data that you need in real time available to to do modeling on and create the triggers. But that I think the ability to do early intervention with patients and the ability to identify early when there's been a potential adverse event or a serious unanticipated outcome allows us to get in, especially to do the communication with family early, is really important. And I I think also the the other piece when we talk about this that is really important to emphasize is that the real utopia here is not doing early intervention when things are starting to go wrong or when when there's been something that's triggered a series of of errors or other other uh system factors that can lead to an adverse event. The real utopia is to get to the next level with data and signals telling us where our risks and hazards are before it actually impacts a patient. And I think that that's the future. That the 10 years ago, we all thought we'd be there by now. I think it's been a little slow. But it's useful, I think, to talk about how we frame our safety strategy at Med-Star Health to put it in context. The way we look at it, we really focus on proactive. And I think we all feel like all of us who do safety in healthcare feel like we spend too many of our resources and too much of our team's time is spent on reacting to events and not enough on preventing future events. And, you know, for systems that use the getting to zero mantra as a as a goal, it's it's always important to remember we can, like technically, you can't get to zero if your only way to learn is after an event, right? That that you just that's by definition, you can't get there. So we have modeled our way of framing safety management after the cardiological. Remember cardiology in the 70s, after like the Framingham study and and everything came out. The remember the prevention of medical disease framework where they had primary, secondary, and tertiary prevention of heart disease, sorry, of heart disease. And primary prevention was like teaching people early on so that they would not acquire risk factors of heart disease, anything controllable, like teaching kids not to smoke, getting people on a good diet, all that kind of thing. That's primary prevention of heart disease. Secondary prevention is identifying people with underlying risks of heart disease like atherosclerosis and other issues, and then controlling that before they have a heart attack. And then tertiary prevention is managing after a heart attack, you know, managing lifestyle and all that. So we use that as an analogy. And we said the way that we want to manage safety is first of all, we should do primary prevention of safety problems, which means actually designing the system for safety, making sure we're selecting and training people properly, making sure our processes are in place to optimize safety, making sure when we acquire medical devices that safety is a major consideration and when we implement them, et cetera. That's creating a framework of a system that is optimized for safety. And we call that primary prevention of safety events. Secondary prevention of safety events is just like the analogy in heart disease, identifying underlying risk that's in the system before it's injured a patient. And then tertiary is after the event, and that's what I just described, those four things after an event that we want to respond to. Where I think the highest yield is for us in the future in becoming safer as a health, as a health system, is in that second component where we have everyone that goes to work every day and takes care of patients in a health system knows where their risks are. We all feel it, we all encounter it every day. And the problem is we're we're so complacent to that because we've with healthcare is so complex and so fast moving. And we're so good at resilience. You know, people keep everything safe day to day. We're kind of navigating through all the risks and hazards that I think as a health system in this country, we've become complacent about reporting this stuff and really pointing it out. Or it may seem small to each individual, but nobody's capturing the essence of a trend. So I think that's where our future is. If you want to talk about like triggers, using data, it's we need to take all the different data feeds available to us and train them to start giving us a daily notice of where the risks are that we need to mitigate before we injure a patient. And this isn't just like we all go to where our heads immediately go is our reporting systems. And definitely our reporting system partners out there need to get better. And I think many of them are exploring this in a smart way is how do they use new technologies to pull trends out? But there's also things like patient complaints, patient feedback, even satisfaction surveys. There's things like IT help desk tickets. There is so much data out there, in addition, that can give us information about where our risks and hazards are. There's in the biomedical engineering world, et cetera. And you can think of the analogy in aviation. They have the NASA has reporting system that's completely voluntary and protective, that they they do a lot of proactive change in aviation before an incident occurs based on data that they pull out, trends that they pull out of these reporting systems. So I think that's where the most important triggers are. We always think of the triggers of real-time things starting to go wrong in the in the acute care setting, which I think is important. But where the money really is and where our future really is and becoming ultra safe is in that second stack, that the what I call secondary prevention, understanding where our existing risks are and really trying to mitigate them in a smart way.

SPEAKER_00 29:31

Yeah, I mean, it's it's a refreshing perspective just to hear the idea of this secondary prevention. If in some future we're doing the secondary prevention well, does that then free us up or fuel us to be able to do, you know, primary prevention, to see, to design things in a better way from the start or something like that? Is that the ultimate vision?

SPEAKER_01 29:52

Yeah, you know, it's an interesting question because we all have limited resources, right? And um we we have a lot of smart safety scientists at Med Star Health that are involved in safety leadership that understand all of this, and still we spend a lot of our time reacting, and we all have limited resources. So I think it's a combination of two things. One is you do have to, I think, start to prioritize, and we've done this a lot, prioritize the events we respond to. Not everything needs a full event review to learn from. And by doing that, you can free yourself up to do more of the proactive work, both primary and secondary. But to answer your question, I think for us to get to Utopia, we need to really do both, well, really do all three well, because you have to learn from events. And of course, learning from events means not only the things that contributed to that event, but you always learn about other risks and hazards when you're deep in the event review space. So, but it's also doing really doing a good job at planning for safety in the first place, you know, and device implementation, etc. But as you're pointing out, like the real high yield is is figuring out where the existing risks are. To do that though, kind of leads to what my, you know, one of my big messages in this podcast would be we're not once we identify, well, two things we're not good at in this country in healthcare. One is we're not good at really identifying the true underlying contributing factors when an event occurs. We think we found the answer, but we don't go deep enough and we don't find all the system contributors. But the second thing we're not yet great at is once we've identified a risk or a hazard or something that is a contributing factor to an event, we often don't match up the correct mitigation in a way that is going to create a sustainable and effective solution. And I always think when we when we've identified a risk that needs to be mitigated, that mitigation has to be both effective and sustainable. Because you can think of you can think of ones that are effective, but six months later nobody's doing it, so it's not sustainable. You can also think of ones that are sustainable and can be going on forever, but it's actually more work is imagined, and it's not truly affecting or improving like we think it is.

Human Factors Center And Leadership

SPEAKER_00 32:31

Yeah, and and that I think dovetails nicely into another topic which I wanted to talk about with you, which is the the National Center for Human Factors in Healthcare. Um this is, as I understand it, a center that you founded and has has grown and is doing a lot of great research in human factors. Um I wonder what you can kind of tell me about the national center as it is today.

SPEAKER_01 32:54

Yeah, well, I'll start with what it is today, and then I think it's a good story to say how how it got there. I think it's a good leadership story actually in Med Star Health. Uh, it speaks well to Medstar Health's approach to this kind of thing. So the National Center for Human Factors in Healthcare is part of the Med Star Health Research Institute. It's a primarily research-driven uh organization that brings in outside safety experts, people who come from different um specialties in safety, but primarily human factors engineering or other forms of human factors, um, safety scientists, if you will, and combines them and integrates them with clinical experts to bring the two ideas together. And this comes from my background that I described in the beginning. I really saw this disconnect of safety scientists, and there's a lot to safety science, but I had really come out of the human factors engineering approach to safety. Um, there's a real gap in having safety scientists understand the domain of healthcare, and there's a gap in having healthcare leaders understand safety science. So the the center was created in 2010 as a solution to that. Med Star Health um put forward a small startup of a few FTEs for a couple years with the promise of being able to build using grant funding, build a center. And that's exactly what happened. It very quickly grew. It's have had over $40 million in external funding. And uh it's been primarily externally funded as a as a grant and contract organization that does lots of different projects, all focused on safety and all focused on integrating human factors uh uh with clinical work. Um and I led it, uh it's been it's been around for about 16 years now. I led it for the first half and then handed it off to Raj Ratwani, who uh um helped me build it. He was my PhD partner. He's a human factors engineer, and he's continues to lead it today, and he's also a vice president of our research institute. Um and the the center has had a lot of national influence. I'm very proud of how much we've influenced policy, especially around EHR safety design, but also medical device uh usability and design and other safety factors in healthcare. But I'm also really proud of how much having human factors, engineers, and safety scientists embedded in our health system has influenced the way our health system leaders think about safety. And I think that's been a real game changer for us. And here's the leadership story part of it. It's because our senior leaders, from our CEO to our chief medical officer, chief nursing officer, the hospital presidents, people in our system really understand how important it is to aggressively go after safety in order to create a safe environment. And it's been a commitment of the health system for the last 20 years, and it's part of our what we call critical capabilities and our strategy is doing everything we can to maintain highest quality and safety. And the investment in the Human Factor Center as an innovation 15 years ago is a is a good um is a good show of that. And it's a good story because I at the time, you know, and I told you in the beginning about the sequence of my career, you know, I was a safety engineer, then I went to medical school, did an emergency medicine residency. And the first decade of my career I spent at the University of Rochester, which had a really good infrastructure for mentoring and developing acumedicians, um, particularly in emergency medicine. It was a really good academic emergency medicine center. I had good mentorship, and I built an early program there applying human factors in healthcare. And then in 2010, I needed to move closer to the DC area for family reasons. I shopped it around to all the academic medical centers in the DC, you know, within a couple of a couple hours of DC. And most of them were very traditional about, yep, come join our emergency medicine faculty, um, and you know, work on your grants, build your center. And Med Star Health took it a step further and and I was selling a vision of within five years I could get enough funding to fund a few PhD partners to work with. And um, Med Star Health said, why don't you send us a proposal on what it would take to start with a few people and where you think we'd be in five years if we started with that? And that was this investment. They were interested in innovation and they were interested in highest quality and safety, both as part of their strategic plan. And they saw this as marrying the two. And it really it's a good leadership story because it really paid off with that being able to bring in a couple smart PhDs early on, including Raj, uh, who now leads the center. We were really able to build it quickly.

SPEAKER_00 38:07

Yeah, and you you hit on uh you know a lot of key points that I I wanted to ask about

Why Quality And Safety Differ

SPEAKER_00 38:12

there. One one thing that um that came up in our earlier discussions was uh distinguishing improvement competencies or skills around quality improvement versus safety competencies. And I think this is this is not always clear to people in terms of you know titles, for example, leadership titles, there's a lot of lumping safety and quality and improvement and other other words together. Um, how do you think about those as distinct competencies?

SPEAKER_01 38:40

It's a great question. And and actually I always I always like to point out to people if you're if you're a quality and safety leader, what's your elevator speech if you get in the elevator with the CEO and and the CEO says, hey Terry, you all you lead quality and safety. What's the difference? I've always wondered what the difference is. It's interesting because I I think many of us historically have struggled to really be able to clearly define the difference in healthcare. And as somebody who comes from outside of healthcare and really looked closely at other safety critical complex industries, um, that was a distinction because in other industries it's really well defined. So, so what one of the early things I did as I transitioned to from an academic uh physician to a physician leader, which you know, that's been my kind of career progression since starting the Human Factor Center, is I really thought we needed the general leader at our organization, everybody, not just quality and safety people, but everybody needed to understand the difference. So we I looked at references, and what we came to is from a patient's perspective, quality is really a measurement on how good your quality of care is against the benchmark. And it's a quantitative thing. So I say the easiest way to understand it is from the patient's perspective. Patients say, how does my care measure up against best practice? That's the and quality, clinical quality is something we measure quantitatively. We we have a number, we have a rate, we have some kind of number that we can benchmark against other health systems. Safety is very different. Safety is don't harm me. There's so much interaction between the two. Obviously, if you have a safety event that happens frequently, it becomes a quality metric. So these are so interactive. It's always important to say that whenever I talk about the distinction between quality and safety as specialty areas, health equity is a really important other area that that flows into both. And that's when the patient says, Do I have a fair opportunity to be healthy and to receive high quality care and to be safe? And and we build health equity into everything we do in quality and safety. So whenever I talk about this framework, I always think it's important to emphasize that. And the second thing to emphasize is from a patient's perspective, they don't care. They want high quality care. When they when they walk in, if you think of the of the IOM report in 2001, remember the IOM had this wheel with six components to quality, which included efficiency, equity, effectiveness, patient-centeredness, timeliness, and safety. So, and it's okay. From a patient's perspective, high quality care includes all these things, including safety. So when I talk about this distinction, it's really important to say that the reason it's important is not because it matters to the patient. The patient expects high quality, safe care. They don't care about what the difference is. The reason it's important to make this distinction as leaders is the suite of competencies and skills professionally that people need in order to improve clinical quality is different than the competencies and skills that people need in order to ensure a safe environment for the patient. And I think that the conflation, what I call the conflation of quality and safety competencies in US healthcare system, is a big part of the problem of why we're not getting safer fast enough. I mean, we all, there's always debate out there about in healthcare in North America, are we getting safer? Some say we're not, some say we are. I I think what we all can agree on is that we're not getting safer fast enough. And one of the reasons we're not getting safer fast enough is most of our leaders in North America, who whose title is that they lead safety, have not had any training in safety or very minimal. Many of them have had Lean Six Sigma, Plan Do Study Act, like those traditional industrial engineering, process engineering, process improvement training, which is really, really important and really good for managing clinical quality. Because clinical quality, if you have an outcome you want, like you want to reduce CAUDI or CLABSI, you want to get to the number, you know the standard of care is you need this bundle of five things in order to optimize it. It takes really good process engineering to do that. That is different than protecting patients from adverse outcomes from random safety events that can occur. The competencies needed for that kind of work include things like really understanding human error at a gym reason or Rasmusin level, understanding the three kinds of human error, how do we mitigate each kind of human error, understanding complex systems theory, systems thinking, um, resilience engineering, human factors engineering, how to put an effective mitigation in place, how to lead a culture of psychological. Safety and reducing cognitive bias and misdiagnosis. It's a whole different schooling. And when you one of the things that really struck me, I I came upon this kind of slowly, but what one thing is I would put out uh job announcements for a patient safety leader, and I would get resumes from people who would start the the cover letter about being a black belt in Lean Six Sigma. But then when you look, they just had no safety training. And I realized that people just didn't understand this distinction. Now, I've talked about this a lot uh in the last several years. And when I talk about it, one of the reactions that I often get that it's important to address is people feel like I'm trying to separate quality and safety. And so it's important to say that's not the goal. I have, I in my job, I do both quality and safety. As a chief quality and safety officer for our health system, I'm responsible for quality, safety, infection prevention, and health equity. And I think I'm good at both. And I have leaders on my team all over the place who do both. The reason they're good at both is because they're trained in both. So I'm not a proponent necessarily of separating it. What I'm a proponent of is if we have people responsible for clinical quality, they need to be really good at process improvement techniques. They also under need to understand, by the way, in the US, how they optimize things like star ratings and leapfrog and and value-based payment and all that kind of thing. But if they have safety in their title, they also need to be trained in the things that make you good at safety at safety management. And other industries, other complex high high-risk industries have embraced this for many, many years. They they have often separate quality management departments and safety departments. And again, I'm not I'm not advocating for separating departments, but they really do have people who have careers in these different spaces.

SPEAKER_00 46:10

Yeah, and and certainly important to highlight those because I think as you've already said, the uh the quality improvement skill set maybe gets a little more airtime. So uh, and is that something that the the national center is is also doing in addition to the research? Is that offering uh training in safety-related skills or is that separate?

Resources, Contact, And Farewell

SPEAKER_01 46:30

Yeah, uh, National Center for Human Factors and Healthcare um has for many, many years we've done training. We do workshops, we'll do basic workshops in human factors. We've also helped other organizations as they do it. We try to be really we we take we always think collaboration beats competition in every way. And there's lots of organizations around the country that do this kind of training for people. We worked with the Institute for Healthcare Improvement as they were developing a board certification for human factors professionals. Uh, we helped develop their curriculum to train to to help people with the review, review, and preparation for the exam. We do workshops on event review training because we're very proud of our systems-based event review that we developed here. Years ago, we were part of the um AHRQ CANDRE grant funding. And CANDR is a is a process that AHRQ developed that includes there's a lot around early communication with patients and families and the medical legal work on that. What our team, the human factors team, and our safety team developed together is the event review program that's that's in that. That it's our it's kind of a it's an evolution of the Med Star Health Systems-based event review program. And we also contributed very heavily to the development of NPSF at the time and now the IHI RCA Squared program, which both of those, both the candor of review and the RCA squared event review, I think really get to this um safety competency piece of really trying to do things better and differently uh in terms of understanding the risks and mitigating the risks.

SPEAKER_00 48:14

Yeah, I'm familiar with the RCA2 framework as well. I'll make sure to include links to all the relevant um uh resources that you mentioned there, including the National Center's website. That's that's great. I mean, I think there's there's so many other things that we can talk about in this in this space, but I you know, I do wonder whether this is you know the best place to kind of round out the conversation for today. Uh for listeners who who would like to to follow you to connect, uh, how would they best do that?

SPEAKER_01 48:43

My most active social media is LinkedIn. It's just simply Terry Fairbanks. That's where I am most active. People are welcome to email me. Also Terryfairbanks at medstar.net. And I've I don't use Twitter as much anymore, and I'm pretty slow at Instagram, but I'm on there somewhere.

SPEAKER_00 49:07

Fair enough. For the for all of you who are professionally networking on Instagram, you can find him. Very good. Well, well, thanks so much again, Terry. Um, appreciate your time so much, Dr. Charity Fairbanks. And uh, you know, this has really highlighted you know, such an important and perhaps under underrecognized, underappreciated area um within our our quality and safety world. Um so I'm so so grateful to you for telling us about Annie's story for the for the National Center for for Human Factors. So grateful for that. And uh I look forward to another episode in the future where we can maybe dive a little deeper into even more of these topics. Great. Thanks, Jason. Appreciate it. Good to talk to you. Thanks so much for listening to today's episode of Leading Quality. If you enjoyed the show, please take a moment to like, subscribe, and share it with someone who might find it useful. You can find all our episodes at leadingquality.buzzsprout.com or in your favorite podcast app. The show is written and hosted by me, Jason Meadows, edited by Milan Milosavievich, and produced by Thrive Healthcare Improvement. See you next time.